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Email triage for new neurological outpatient referrals: what the customers think
  1. V Patterson1,
  2. C Donaghy2,
  3. L Loizou3
  1. 1Centre for Online Health, Brisbane, Australia
  2. 2Royal Victoria Hospital, Belfast, UK
  3. 3Pinderfields Hospital, Wakefield, UK
  1. Correspondence to:
 Dr Victor Patterson
 Teleneurology, 1st Floor Education Centre, Royal Victoria Hospital, Belfast BT12 6BA, UK; tele.neuro{at}

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When patients with neurological symptoms are referred to a neurologist by their general practitioner (GP), the neurologist acquires two customers—the patient and the GP. If the neurologist plans to introduce a new or changed service it would be considered good practice to seek the opinion of the people using the service—the customers. Such an approach is commonplace in other walks of life, but is rarely used in medicine.

We used this approach when considering changing from a letter-based referral system for new referrals to one based on email. Email can be used to triage referred patients into those who need to be seen in a clinic and those who can be managed without entering the clinic system, either by investigations or by simply offering advice. This approach has been used successfully for general medical patients in Finland1 and we have shown that in neurological practice this novel method is feasible, safe, sustainable and saves neurologists’ time.2,3 A similar system is being introduced within parts of the UK National Health Service for a variety of specialties under the title of Integrated Clinical Assessment and Treatment Services.4 The email service provides a response to the GP within 48 h, but if the referral is dealt with by simply providing advice or by arranging investigations, the patient will not be seen in person by the neurologist. When we presented our results at neurological meetings, one objection raised against the email system was that patients and their GPs would be unhappy that a referred patient may not see a neurologist in person. To test this hypothesis we carried out a customer survey.


The study was carried out in two different parts of the UK, general neurology clinics throughout Northern Ireland and waiting list initiative clinics in Pinderfields Hospital, Wakefield, Yorkshire.

Patients were new referrals from GPs who had been referred conventionally by letter and whose degree of urgency had been graded by the neurologist as routine. They had generally been waiting between 3 and 6 months for their appointment.

Their opinion was obtained while they were waiting to be seen by the neurologist. The approval of the ethical committee was not required.

Patients were asked to choose between the two possible referral methods that were presented to them on a single sheet of paper. The sheet was given to them by the clinic nurse or receptionist, with a short written explanation, and the completed sheet was collected from them before they saw the neurologist, who was unaware of the results when seeing the patient.

GPs were chosen in Northern Ireland by geographical spread, excluding County Fermanagh, where the email system had already been introduced. They were contacted by telephone by one of the authors (CD) and the questionnaire was filled in over the telephone.

GPs in Wakefield were chosen from hospital referrers. They were contacted first by an explanatory letter enclosing the questionnaire and if this was not returned, one of the authors (LL) followed up by telephone.


Overall, 80 % of patients in Northern Ireland (n = 100) and 91 % of those in Yorkshire (n = 100) preferred the email system. GPs also preferred the email system, although 50 less enthusiasticaly 80% GPs from Northern Ireland (n = 50) and 51% in Yorkshire (n = 82).


Most new patients and GPs in two parts of the UK would prefer an email triage system compared with the current system of hospital referral. We carried out this study on patients who were within the system but had not yet completed it and who therefore had good knowledge of what the conventional system included. All the GPs had first-hand knowledge of referral of patients to their local neurologist. The wording of the questions was direct but encapsulated the implicit trade-off between an early opinion with the possibility of not being seen by a specialist against a delayed opinion with the guarantee of being seen by a specialist.

We do not find these results surprising. The existing system of referral is impersonal and inefficient. Hospital referral letters are usually unstructured and many are still hand written and often difficult to read. An email with a proforma encapsulates what the GP wants to gain from the consultation and the rapid response from the neurologist brings a degree of personal interaction that is completely lacking in the conventional system. A competent neurologist, from a description by a competent GP, can easily diagnose many neurological symptoms of patients. Patients can then either be reassured without being seen or have appropriate investigations carried out without entering the hospital system. A follow-up of more than 150 patients by this system has shown that, when carried out by an experienced neurologist, this practice is safe and saves neurologists’ time.3 Benefits accrue to both patients and their GPs and also to neurologists who will see patients in the clinic more relevant to their skill and experience. A wider adoption of this system requires neurologists and GPs to change their practice and such changes are known to be difficult. Whatever the arguments proposed against these changes, a lack of customer readiness should not be one of them.



  • Competing interests: None.